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Training Doctors, The Importance of Tx Intensity and Patient Preferences?

The Dartmouth Atlas of Health Care recently published a report entitled, “What Kind of Physician Will You Be?: Variation in Health Care and Its Importance for Residency Training.” (2012; http://www.dartmouthatlas.org/pages/residency). Briefly, this report analyzes Medicare data to create indexes and variables used to describe varying levels of treatment intensity, particularly at the end of life, for 23 top U.S. medical centers. This report is targeted to medical students who are choosing their residency programs, hoping that prospective residents look at a wider-array of factors, including: how well these hospitals utilize effective, proven health care interventions; to what extent the care they provide is dependent on supply-induced demand; and how well the hospitals allow for patient preferences in treatment plans.

This report grabbed my attention given that I conduct research in end-of-life (EOL) care, and I am sympathetic to efforts to improve the quality of care provided to people with advanced and terminal diseases. I am also quite interested in how our medical system can change the culture of medical care to provide higher-quality EOL, and to reduce the use of often ineffective and invasive medical interventions, particularly through hospitalization and ICU admissions. The education of residents seems like a good place to start in changing the current intensity and specialty-driven culture.

However, the gaps in this report compromise its arguments and potentially reduce its effectiveness. I will only highlight two here.

First, there is little evidence provided that the intensity of care provided in hospital residency programs actually results in future physicians who follow the same practice patterns. In other words, it seems that more research needs to be conducted, or at least cited, for us to be compelled to urge future residents to choose programs based upon the criteria this report proposes. Perhaps residents see the lack of coordination of care at the “lower-ranked” programs in this report, and learn to know what not to do. Second, the emphasis the report gives to “preference-based care” is somewhat surprising. Although shared-decision making between patients and physicians has an important place in medicine, patient preferences in medical care (or human preferences for most things, for that matter), often vacillate and are frequently ill-informed. What is more important, in my eyes, is that physicians know how to educate patients, how to lay-out the reasonable options, and then how to help guide patients to the most effective care, based upon the goals of care.

For example, this report might want to put more emphasis on the specific communication skills training programs provided in these residency programs. Such training likely more accurately predicts the ability of doctors to provide compassionate, informed and appropriate care – not only about the science of medicine, but also the art of listening to people and guiding them during the final months of life. Or, what do the data say about how well residents fair, on the criteria outlined in the report, who were trained at the report’s highly-rated programs compared to the lower-rated programs?

Again, I commend this report in starting the dialogue about how we want our physicians trained in this country. However, this is a first (or second) step – I hope more is to come on this topic from the Dartmouth Atlas, whose research has had such a big impact on how we view practice patterns in this country.

About Susannah Rose

Susannah joined the Professional Staff in the Department of Bioethics at Cleveland Clinic in the fall of 2011, and she is an Assistant Professor at Case Western Reserve University. She received her Ph.D. from Harvard University's Health Policy Program in 2010. She also earned an M.S. in Bioethics from Union College/Albany Medical Center in 2006, and a M.S. in Social Work from Columbia University in 1998. Before studying at Harvard, Dr. Rose worked as a clinician and researcher at Memorial Sloan-Kettering Cancer Center in New York City, specializing in the psychosocial issues surrounding cancer. While at Harvard, she received multiple awards and fellowships: Susannah was a National Institute of Mental Health (NIMH) pre-doctoral research fellow; a Harvard Edmond J. Safra Center for Ethics Graduate Fellow; a Safra post-doctoral lab fellow; and a pre- and post doctoral fellow at Massachusetts General Hospital, sponsored by the National Cancer Institute (NCI) through the Program in Cancer Research Outcomes Training (PCORT). She also received multiple teaching awards and the Joan P. Curhan Citizenship Award. She has published two books focused on coping with cancer, and she has published and presented in numerous academic venues on topics related to conflicts of interest in medicine, health policy, oncology and bioethics. Most recently, she has published in the New England Journal of Medicine, the Journal of Clinical Oncology, and the Journal of Law, Medicine and Ethics. In addition to her faculty appointment at Cleveland Clinic and Case Western , she is currently a Fellow at the Edmond J. Safra Center for Ethics at Harvard University. Her current research focuses upon two primary areas: 1) conflicts of interest and institutional corruption, and 2) outcomes in end-of-life care.